Healthcare Provider Details

I. General information

NPI: 1831609098
Provider Name (Legal Business Name): HEATHER MARIE BRUCKSCHEN LPC, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER M ANTONIEWICZ LPC-IT, SAC-IT

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 REED AVE
MANITOWOC WI
54220-2020
US

IV. Provider business mailing address

339 REED AVE
MANITOWOC WI
54220-2020
US

V. Phone/Fax

Practice location:
  • Phone: 920-208-6773
  • Fax:
Mailing address:
  • Phone: 920-208-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17149-132
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11268-125
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100074973
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: